Provider Demographics
NPI:1356128029
Name:PETTIGREW, LISA RUSSO (RSMT, PHD CANDIDATE)
Entity type:Individual
Prefix:
First Name:LISA
Middle Name:RUSSO
Last Name:PETTIGREW
Suffix:
Gender:F
Credentials:RSMT, PHD CANDIDATE
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:PO BOX 6300
Mailing Address - Street 2:
Mailing Address - City:CRESTLINE
Mailing Address - State:CA
Mailing Address - Zip Code:92325-6300
Mailing Address - Country:US
Mailing Address - Phone:909-336-3330
Mailing Address - Fax:
Practice Address - Street 1:340 S STATE HIGHWAY 138
Practice Address - Street 2:
Practice Address - City:CRESTLINE
Practice Address - State:CA
Practice Address - Zip Code:92325-9153
Practice Address - Country:US
Practice Address - Phone:909-336-3330
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2023-09-14
Last Update Date:2025-02-06
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes102L00000XBehavioral Health & Social Service ProvidersPsychoanalyst
No172V00000XOther Service ProvidersCommunity Health Worker